Primecuts-This Week in the Journals

May 3, 2010

 The 21st Running of the City of Pittsburgh Marathon

 Michael Ford, MD

Faculty Peer Reviewed

I am filing this dispatch from Pittsburgh, Pennsylvania.  A former home of steel, bratwurst, Iron City Beer, and cigarettes, Pittsburgh today finds itself lurching somewhat awkwardly along a transitional path toward gleaming healthcare and biotech excellence.  This location seems appropriate, as it was home to me for 10 years prior to relocating to NYC to begin a medical career.  It was here that I became a runner and attained the best fitness of my life, but today I lurched awkwardly and painfully through only half of a proposed 26.2 mile course, hobbled by six years of bad health choices, too little time for meaningful exercise, and additional pounds.

 Several years ago, while buying car tires in the automotive department at a Pittsburgh area Wal-Mart, I was shocked to see a rack of candy bars at the register – compulsion items meant to lure a wealthy and insatiable customer.  In further proof that our formerly adaptive appetites and physiology have been far outpaced by changes in our environment, The New York Times recently reported on the obesity epidemic in Qatar1.  In a country the size of Connecticut – where 250,000 natives have been made fabulously wealthy thanks to epic stockpiles of oil and natural gas, and now suddenly find themselves waited on by over one million foreign-born workers – approximately 70% of native Qataris are expected to be obese five years from now.  Rates of diabetes and its well-documented entourage of blindness, heart disease, and kidney failure are expected to follow.  The health care system in that nation is geared toward disease treatment, with a fledgling but still miniscule emphasis on prevention.  In the course of several generations, oil has allowed Qataris to trade an existence of toil in the desert for one of Land Rovers and opulence.  If only their physiology were so malleable.

 The Qataris aren’t alone, of course. A similar problem has been at work in Western society for a much longer time.  Obesity is a problem of human nature, primarily.  In an existence of deprivation and infrequent meals, over-consumption, extraction, and conversion into storage of calories when they happened to be available, as well as sloth as a means of energy conservation, were adaptive traits.   

 Kvaavik and her colleagues recently reported on the long-term health consequences of poor lifestyle choices2.   In their study (The United Kingdom Health and Lifestyle Survey), almost 5000 people 18 years and older were enrolled in 1984-1985, after which they were followed prospectively for a mean period of 20 years.  A survey was completed by the participants at enrollment, and points were allocated for smoking and excessive alcohol consumption (defined as more than 14 units weekly for women, 21 for men; one Unit is equivalent to eight grams of alcohol, and a pint of lager or a large glass of red wine each contain about three Units), less than three servings of fruits and vegetables daily and less than two hours of physical activity weekly.  Despite the fact that this survey sets the bar for excessive alcohol consumption substantially lower than our current recommendations for “safe” alcohol consumption, and even though the health behavior survey was performed only at the beginning of the study period and therefore cannot account for lifestyle changes (good or bad) that occurred during the follow-up period, adjusted hazard ratios and 95% confidence intervals for total mortality associated with 1, 2, 3, and 4 poor health behaviors compared with none were 1.85 (95% CI, 1.28-2.68), 2.23 (95% CI, 1.55-3.20), 2.76 (95% CI, 1.91-3.99), and 3.49 (95% CI, 2.31-5.26), respectively.  The P value for this trend was <0.001.  Compared to people with no poor behaviors, those with all four had a death risk equivalent to people 12 years older than themselves.  Thus, despite obvious flaws, this study puts solid numbers on an association between poor health choices and outcomes that most of us have already accepted as fact. Next time you run through the CAGE questions, or talk to your patient about smoking cessation, nutrition, or exercise, your conversation can at last be more “evidence based!”  But, will you bother to have that conversation, or just wait until your patient has a myocardial infarction and let the interventional cardiologists step in?

Just as human nature seems to tend toward greed and sloth, so too perhaps we prefer to solve a problem once it is apparent, rather than try to prevent it by anticipating it in advance.  After all, why waste energy trying to prevent something that may or may not come to pass?  The result of a successful preventive endeavor is indistinguishable from the feared event never occurring in the first place.  Which may explain why not only the Qatari health care system, but our own as well, focuses on disease treatment rather than prevention.  And yet we now have sufficient experience with many medical illnesses to accurately predict the future, making prevention a worthwhile enterprise.  But nobody knows how to pay for it.

 The health care reform legislation recently passed by Congress promises to insure 32 million new patients at a time when primary care is already overstretched and under-compensated, causing most new doctors to avoid the field.  In fact, less than 10% of current medical school graduates enter primary care fields, while the vast majority chooses specialties3.  In an enlightening study just published in The New England Journal of Medicine, Richard Baron makes use of his community-based primary care practice’s electronic medical record to account for just what, exactly, primary care doctors are spending their time each day doing4.  On average, they are seeing 18 patients, which at an average of $70 per visit accounts for the bulk of their revenue.  But they are also answering 24 phone calls and sending 17 e-mails.  They are reviewing 19 lab reports, consulting with specialists 14 times, and looking at 11 x-rays.  In 2008, as his data collection for the NEJM article was ending, Dr. Baron’s medical group received funding through a pilot program run by the state of Pennsylvania (and sponsored by large area insurers) that compensates doctors not just for patient visits, but also for preventive health measures and disease management work.  The additional revenue has amounted to an increase over previous office-visit only revenue by 15% annually, allowing Dr. Baron to hire additional staff such as an RN to do “information triage” of phone calls, lab reports, and consultation notes.  The physicians in his practice are now paid using an internal productivity metric that takes phone calls and e-mails into account.

 Programs like this are rare, and the status quo still heavily reflects a reliance on specialists.  Expanding these programs will require funding.  In the absence of a new source of revenue, this money may need to be redirected from specialists’ pockets.  And yet, if we do not find ways to incentivize high quality primary care, chronic disease management, and preventive health, our current health care system could collapse under its own weight.  As millions of patients both established and brand new find themselves without access to quality primary care, their resulting mismanaged medical conditions will lead to inevitable (and in many cases, avoidable) outcomes, including their (metaphorical) stampede to the cath lab.

 A final word.  A major theme of this essay has been the awkwardness of transition – in human ecology, in societies, in cities, and in health care systems.  And the possibility of reinvention.  The Pittsburgh Marathon was held annually starting in 1985, but was canceled after the 2003 race when the city fell on economic hard times.  It was resurrected for the 2009 running, and this year, with 16,000 entrants, marks a high point for the race.  The success of the re-born marathon reflects the progress of the city.  Decades after the death of big steel, Pittsburgh is now clearly on the path to becoming that modern city envisioned so many years ago.  The end of residency is looming for many of us, and the massive U.S. healthcare system is lurching somewhat awkwardly along a transitional path toward… what exactly we’re not entirely certain.  And yet, this moment feels like an opportunity to carve out a professional place where patients’ preventive health concerns are no longer ignored in favor of fancy diagnostics and treatments after the fact.  And perhaps it also represents a chance to resurrect some healthful practices in our own lives.  I think I might be able to make it through all 26.2 miles next year.

Dr. Ford is a second year resident in internal medicne at NYU Langone Medical Center

Faculty Peer Reviewed by Barbara Porter, MD Section Editor, Clinical Correlations

 1. Slackman M. Privilege pulls Qatar toward unhealthy choices. The New York Times (New York Ed.) 2010 Apr 27; Sect A:4.

 2. Kvaavik E, Batty GD, Ursin G, Huxley R, Gale C. Influence of individual and combined health behaviors on total and cause-specific mortality in men and women (The United Kingdom health and Lifestyle Survey). Arch Intern Med. 2010 Apr 26; 170 (8): 711-718.

 3. Lohir S. Study shows ‘invisible’ burden of family doctors. The New York Times (New York Ed.) 2010 Apr 29; Sect B:3.

 4. Baron RJ. What’s keeping us so busy in primary care? A snapshot from one practice. NEJM. 2010 Apr 29; 362 (17): 1632-1636.